Preventing Tearing During Birth: What 31 Trials Found

Pelvic floor training during pregnancy is the best-supported thing you can do yourself to lower your chance of tearing at birth.

In a 2026 review of 31 randomized trials and more than 10,000 women, antenatal pelvic floor exercise ranked first for preventing tears and was linked to roughly half the risk. It shifts the odds and doesn't guarantee an intact perineum, so it works best alongside guidance from a pelvic floor physiotherapist.

Tearing is one of the fears women bring up most often in the last weeks of pregnancy, usually right at the end of an appointment, once the "real" questions are done. For a long time we prescribed perineal massage but found that compliance was generally quite low. The research has moved, and the now gives us other alternatives that show promise in.

What counts as a tear, and how common it is

The perineum is the stretch of skin and muscle between the vagina and the anus, and it stretches a great deal as your baby's head is born. Many women tear a little during a vaginal birth, especially with a first baby, and most of those tears are small and heal well. Tears are graded by depth from first degree (skin only) up to third and fourth degree, which involve the muscle around the anus.

Being common doesn't make it something to simply accept, and there are things that improve your odds.

What the 2026 review compared

Researchers pooled 31 randomized trials from 15 countries, 10,745 women in total, and used a network meta-analysis to compare the physical approaches people use to protect the perineum. That method lets trials that never tested two approaches head to head still inform a comparison between them, and it produces a ranking of which approach is most likely to help.

Pelvic floor training during pregnancy ranked first for reducing tears overall, with about half the risk of tearing (relative risk 0.50). Perineal massage combined with warm compresses during pushing ranked first for avoiding an episiotomy, and massage was linked to more women finishing birth without any tear. Education on its own, without practice, showed no effect.

The limits worth knowing

A ranking tells you which option is most likely to come out ahead, which is different from saying how sure we can be. The authors rated the evidence for tearing as moderate certainty, mainly because results varied from trial to trial. The range around "half" is also wide, from roughly a 13% reduction to a 72% reduction, so the true effect could be smaller or larger than the headline.

Most of the women in these trials were having their first baby, so we don't know yet whether the benefit holds as strongly for second and later births. None of this cancels the finding. It means training improves your odds, and no one can promise how a single birth will go.

Why practice beats information

The detail that stays with me from this review is that education alone made no difference. Knowing that your pelvic floor matters is a good start, and the change in the trials came from the women who practised. A pelvic floor that's strong and can also relax fully is the goal, because the letting go is what you need when it's time to push.

One small, older study of 47 women found that after brief verbal instructions only about half could do an ideal pelvic floor contraction, and a quarter were doing something that could make leaking worse. That's the case for having someone check your technique at least once, rather than guessing on your own for months.

Where to start

Lie on your side with a pillow between your knees. Breathe out and gently lift your pelvic floor as if you're stopping wind and the flow of urine at the same time, hold for a slow count of three, then release completely. Ten repetitions a day is a reasonable place to begin. If you feel pain or leaking at any point, or can't feel anything happening at all, see a pelvic floor physiotherapist before you carry on.

If you'd rather not guess, a pelvic floor assessment is the best next step. Tara, Nicole and Nikita, our pelvic floor physiotherapists, check how your muscles lift and let go, then prescribe exercises that fit your body and where you are in your pregnancy, so the weeks you put in go toward the right thing. Book a pelvic floor assessment.

Frequently asked questions

Can you prevent tearing during birth?

You can lower your chances. A 2026 review of 31 trials found pelvic floor training during pregnancy was linked to about half the risk of tearing, and massage with warm compresses was linked to fewer episiotomies. Nothing guarantees an intact perineum.

When should I start pelvic floor exercises in pregnancy?

The trials trained women during pregnancy, and the review's authors suggest starting in the second trimester. Earlier gives you more weeks of practice, and a pelvic floor physiotherapist can tailor the timing to you.

Does perineal massage help?

In the same review, perineal massage combined with warm compresses ranked first for avoiding an episiotomy, and massage was linked to more women having no tear at all.

Does birth position prevent tearing?

A separate 2026 review of nine trials found no clear difference in tearing between upright and lying-back positions, so the authors suggest choosing the position that feels right for you.

References

Xu L, Li T, Jin J, Zhang L, Luo Z. Comparative effectiveness of physical interventions for preventing perineal trauma during vaginal delivery: a systematic review and Bayesian network meta-analysis. Front Med (Lausanne). 2026;13:1794056. doi:10.3389/fmed.2026.1794056. PMID 42023089.

Laderas-Díaz E, Rodríguez-Almagro J, Martínez-Rodríguez S, Picón-Rodríguez R, Hernández-Martínez A. Maternal positioning in the second stage of labour and its relationship with perineal trauma: a systematic review and network meta-analysis. Int Urogynecol J. 2026;37(5):1167-1177. doi:10.1007/s00192-025-06512-4. PMID 41572012.

Bump RC, Hurt WG, Fantl JA, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991;165(2):322-329. doi:10.1016/0002-9378(91)90085-6.